Pap Screening of HIV+ Men Reveals Half Have Abnormal Cells
than 80% of HIV positive men agreed to undergo Pap screening
for anal cancer, demonstrating its feasibility, and 53%
showed signs of potentially pre-cancerous abnormal cell
cancer remains a concern for people with HIV
despite the advent of effective combination antiretroviral
therapy (ART), which has reduced
rates of AIDS-defining cancers.
by high-risk types of human papillomavirus (HPV), anal cancer
is not considered an AIDS-related cancer (as is cervical cancer
caused by the same HPV types). However, it is more common
among HIV positive compared with HIV negative people, and
studies indicate that the risk rises with declining immune
Pap smears -- a test that examines a small sample of cells
for abnormal growth that could progress to cancer -- is not
currently part of the standard of care for people with HIV,
but a growing number of experts think it should be. By detecting
cell abnormalities at an early, more treatable stage, expanded
anal Pap screening could reduce anal cancer deaths, much as
widespread cervical screening has done for cervical cancer
the present study, published in the March
31, 2011, issue of AIDS Patient Care and STDs,
Isabella Rosa-Cunha from the University of Miami and colleagues
assessed the acceptability and feasibility of screening for
anal intraepithelial neoplasia (AIN), or abnormal tissue growth
that can progress to cancer. They also looked at the relationship
between presence of anal neoplasia and history of receptive
anal intercourse, which is commonly considered a risk factor
for anal cancer in both men and women.
February and July 2006, the researchers asked 160 HIV positive
adults attending routine visits at a Veteran's Affairs HIV
clinic in Miami if they would be willing to undergo anal Pap
testing. Eligible participants had no prior history of anal
cancer and had not received anal screening before. If Pap
tests were positive, participants received follow-up high-resolution
anoscopy (viewing the anus with a lighted magnifying instrument)
and tissue biopsies; those with abnormal findings were offered
patients (82%) agreed to participate in the study and
undergo anal Pap smears.
were men, 52% were black, 33% were white, 14% were Hispanic,
and the median age was 49 years (range 29 to 80 years).
men had well-controlled HIV disease overall, with more
than 75% on ART and a median CD4 T-cell count of about
regard to sexual history, about 40% reported having had
anal intercourse, nearly one-third reported 4 or more
sexual partners during the past year, and about half had
a history of other sexually transmitted diseases.
men (75%) had anal cytology samples adequate for analysis.
this subset, 53% had abnormal Pap test results:
with atypical squamous cells of undetermined significance
with low-grade squamous intraepithelial lesion (mild
dysplasia or potentially pre-cancerous abnormalities);
with high-grade squamous intraepithelial lesion
(more serious neoplasia or possible malignancy).
participants who subsequently underwent anoscopy with
biopsy, 55% were found to have high-grade AIN, including
2 cases of anal carcinoma in situ (localized cancer).
CD4 cell count was the only significant predictor of abnormal
of anal intercourse was not significantly associated with
abnormal anal cytology results in this study.
cytology was well accepted and it was feasible to be incorporated
into HIV primary care practice," the study authors concluded.
"The high rate of abnormal results reinforces the need
for further evaluation of the role of systematic anal Pap
smear screening for HIV patients."
our study abnormal anal cytology was as frequent in patients
who denied anal intercourse as in patients with history of
anal intercourse," they elaborated in their discussion.
"And among patients with abnormal cytology who underwent
[high-resolution anoscopy], history of anal intercourse was
not predictive of the degree of the dysplasia and the 2 cases
of carcinoma in situ were in patients who denied anal intercourse."
It is possible that self-reports of sexual behavior were inaccurate,
but these findings suggest that screening for anal cancer
should not be limited to HIV positive men who self-identify
as gay/bisexual or report having anal sex.
The researchers also noted that 25% of collected samples were
unsatisfactory for cytology analysis, higher than the proportion
seen in other recent anal Pap studies (4%-9%).
"[T]he results underscore the necessity of specialized
training of clinicians in performing anal Pap smears and of
routinely orienting the patients undergoing anal Pap smear
screening to avoid anal intercourse, anal manipulation...anal
enemas or anal douche within 24 hours prior to sample collection,"
Abnormal Pap smear cytology predicted abnormal follow-up findings,
but not the degree of tissue abnormality. The 2 men with carcinoma
in situ, in fact, had ASCUS, the least serious abnormal Pap
result. This finding, the researchers wrote, "support[s]
the recommendation of further evaluation with [high-resolution
anoscopy] with biopsy of visible lesions of patients with
any abnormal anal cytology." They added that testing
for high-risk HPV types -- as is now routinely done with cervical
Pap tests -- might help improve accuracy.
"HIV-infected individuals benefiting from HAART are living
longer and, therefore, anal cancer in this population will
likely remain a significant medical challenge," they
concluded. "Until there is a consensus regarding anal
Pap smear screening, HIV-infected patients need to know they
are at risk of anal cancer, and anal health should be an issue
of priority for HIV care providers to discuss with their HIV-positive
affiliations: Division of Infectious Diseases, Department
of Medicine, University of Miami Miller School of Medicine,
Miami, FL; Surgical Services, Veterans Affairs Medical Center,
Miami, FL; Department of Pathology, University of Miami Miller
School of Medicine, Miami, FL; Pathology and Laboratory Medicine
Services, Veterans Affairs Medical Center, Miami, FL; Medical
Services, Veterans Affairs Medical Center, Miami, FL; Departments
of Epidemiology & Public Health and Pediatrics, University
of Miami Miller School of Medicine, Miami, FL; Research Services,
Veterans Affairs Medical Center, Miami, FL.
Rosa-Cunha, VA DeGennaro, R Hartmann, et al. Description of
a Pilot Anal Pap Smear Screening Program Among Individuals
Attending a Veteran's Affairs HIV Clinic. AIDS Patient
Care and STDs 25(4):213-219 (free
full text). March 31, 2011.